Provider Demographics
NPI:1336508514
Name:HEIDEN, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:HEIDEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-2524
Mailing Address - Country:US
Mailing Address - Phone:407-552-1510
Mailing Address - Fax:
Practice Address - Street 1:300 W MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-2524
Practice Address - Country:US
Practice Address - Phone:845-208-4671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007510101YP2500X
NJ37PC00574400101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional